Bioterrorism and Weapons of Mass Destruction for Healthcare Providers

## Contact Hours: 4

This online independent study activity is credited for 4 contact hours at completion.

## Course Purpose

To provide healthcare providers within emergency services an overview of weapons of mass destruction, their signs and symptoms, and treatment modalities for various of chemical, biological, radiological, nuclear, or explosive weapons causing that have the potential to cause mass casualties.

## Overview

Terrorism is generally considered to be the use of force or violence outside the law to create fear among citizens with the intent to coerce some sort of ideological, financial, religious, or political action. Terror tactics may include biologic, chemical, nuclear, or explosive events. All health professionals need to be prepared for a terrorist attack. Establishing a diagnosis is critical to the public health response to a bioterrorism-related epidemic because the appropriate diagnosis will lead to effective treatments to reduce the morbidity and mortality associated with a terrorist attack. This learning activity will provide an overview of the various weapons of mass destruction, signs, and symptoms that a patient may present with, and the various treatment modalities to reduce morbidity and mortality.

## Objectives

Upon completion of the independent study, the learner will be able to:

- Define terrorism and weapons of mass destruction.

- Identify resources for information on public health emergencies.

- Associate the various classifications of weapons of mass destruction to their symptomatology and treatment regimens.

- Consider first responder practices and emergency services preparation.

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You are working in the emergency room at your local hospital. While working in the triage area, you encounter a 45 year-old male patient with a vague description of nausea and shortness of breath. Suspecting cardiac symptomatology, you request for a 12 lead EKG. While the EKG is being completed, you encounter another patient, this time a 21 year old female complaining of itching, burning skin, nausea, and shortness of breath. You assess her and your initial differential diagnosis is an allergic reaction. While interviewing and assessing the patient, another patient arrives with her young daughter. The 35 year old mother stated that she was at a local park with her daughter when her daughter began to complain of itchy, burning skin. She says she thought her daughter had some sort of allergy to the grass, but shortly afterwards, she vomited and complained of not being able to breath. The mother stated that she too was experiencing the same symptoms. While interviewing the mother, a group of young men in their 20s arrive to the emergency room. They said they were going to get something to eat at the mall, but while in the parking lot they started to have itchy, burning skin and nausea. One of the young men said that he feels like he is having difficulty trying to catch his breath. You notify the charge nurse on duty that a large group of patients have arrived with similar health complaints, all saying that they were outside when the symptoms began, and they all arrived within an hour. You now suspect that the patients could all be victims of a terrorist attack, and you also suspect that you will have a surge in patients arriving to the emergency room. As part of the emergency services, what else can you do as a healthcare provider to gain accurate information and prepare for the potential surge in patients? The answers to these questions will be revealed as you progress through the learning activity.

Terrorism is generally considered to be the use of force or violence outside the law to create fear among citizens with the intent to coerce an ideological, financial, religious, or political action. Health professionals should be aware that bioterrorism is a perfect vehicle for terrorists to strike fear into the hearts and minds of citizens in the hopes they will bend the will of the people to support their agendas. Terror tactics may include biologic, chemical, nuclear, or explosive events. All health professionals need to be prepared for this potentially catastrophic event.¹

The goal of a terrorist is to create mass hysteria through covert or overt acts. In a covert attack, a terrorist will attempt to take advantage of the element of surprise. If the covert attack is successful, the healthcare system may be quickly overloaded with a large influx of patient volume. Healthcare providers must be diligent in evaluating the possibility of a covert attack when multiple patients arrive with similar signs and symptoms. The sooner a covert attack is recognized, the sooner additional resources can be activated to assist healthcare providers. Unless the system prepares in advance, the number of victims triaged may quickly overwhelm the system and result in the terrorist’s goal of creating mass panic.

In an overt attack, a terrorist will likely rely heavily on mass hysteria and panic as an impact multiplier, and they may announce responsibility immediately afterwards for a large-scale event. The number of victims of an overt attack quickly overwhelms even prepared systems that have a well-defined emergency response plan. In either a covert or overt terrorist attack, the system may be flooded with victims.

Because of heightened concerns about the possibility of bioterrorist attacks, public health agencies have new methods of surveillance that are intended to detect the early manifestations of illness that may occur during a bioterrorism-related epidemic. Syndromic surveillance is a method that covers a broad spectrum of activities, for instance monitoring for illness syndromes or events, such as an increase in medication purchases that reflect the prodromes of bioterrorism-related diseases. The goal of syndromic surveillance is to enable earlier detection of epidemics and a timely public health response before disease clusters are recognized clinically, or before specific diagnoses are made and reported to public health authorities.¹¹

Establishing a diagnosis is critical to the public health response to a bioterrorism-related epidemic, since the diagnosis will guide the use of vaccinations, medications, and other interventions.¹¹

Local health authorities, including emergency services, should examine their preparedness repeatedly for a potential bioterrorist attack and routinely review coordination issues with agencies that take place in response. During a bioterrorist attack, the Center for Disease Control’s Health Alert Network (HAN)is the primary method of sharing cleared information about urgent public health incidents.¹⁰ This information is shared with public information officers; federal, state, territorial, tribal, and local public health practitioners, clinicians, and public health laboratories. The HAN collaborates with federal, state, territorial, tribal, and city/county partners to develop protocols and stakeholder relationships that will ensure a robust interoperable platform for the rapid distribution of public health information. The HAN has four message types: ¹⁰

- Health Alert: Provides time-sensitive information for a specific incident or situation that warrants immediate action or attention and conveys the highest level of importance.

- Health Advisory: Provides important information for a specific incident or situation and has recommendations that may not require immediate action.

- Health Update: Provides updated information regarding an incident or situation that is unlikely to require immediate action.

- Info Service: Provides public health information that is unlikely to require immediate action.

Weapons of mass destruction include chemical, biological, radiological, nuclear, or explosive weapons potentially causing mass casualties. The mnemonic CBRNE assists in remembering weapons of mass destruction:

- Chemical

- Biological

- Radiological

- Nuclear

- Explosives

Chemical Weapon

A chemical weapon is any toxic chemical that can cause injury, sensory irritation, incapacitation, and death. It is usually deployed by a delivery system, such as an artillery shell, ballistic missile, or rocket. Chemical weapons are considered weapons of mass destruction and their use in armed conflict is a violation of international law. During World War I there was widespread use of chemical weapons that often affected the civilian population resulting in many deaths. Since World War I, most countries have agreed not to use chemical and biologic weapons. Unfortunately, with our present age of terrorism from individuals, splinter groups, and dictators, there is an ever-present risk that these agents could be used.

The main forms of chemical weapons of mass destruction include nerve agents, blister agents, choking agents, and blood agents. These agents are categorized based on how they affect the human body. ¹

Biological Agent

Bioterrorism is described as the intentional release of biological agents to cause illness or death in humans, animals, or crops. Symptoms of bioterrorism may not appear for days or weeks. Biological agents include bacteria, fungi, toxins, and viruses, and they may be naturally occurring or genetically-modified. Often the bacteria or virus is weaponized, and the changes will affect a broader segment of humans, animals, or crops than the normal pathogen.

The agents are typically found in nature, but they may be altered in a laboratory to increase their resistance to antibiotics, and ability to spread in the environment. Biological and chemical agents may be spread through the air, food, or water. Terrorists use biological agents because they are often difficult to detect and the onset of illness may be delayed, increasing the spread.

Biologic agents may be spread by several techniques including contaminated water and aerosol sprays. These agents can also infect individuals and who can unknowingly increase the spread through travel on airplanes, buses, or at large events that can quickly spread an agent of bioterrorism.

Bioterrorism agents are a common choice for terrorists because they are inexpensive to produce, easy to disseminate, may have no known vaccine, and are easily transferable from person to cause widespread effects. The challenge with bioweapons is that they may affect friendly forces and enemies. Terrorists use biologic weapons as a method of creating mass panic.Common microbes that can be used as biological weapons include:

In the history of humanity, the intentional infliction of casualties on civilians was considered inappropriate. Civilians are usually not attacked for their own sake unless they happen to be living or working in an area that has tactical or strategic value. Unfortunately, bioterrorism agents are difficult to control and affect military personnel as well as civilian men, woman, and children.

In the last 100 years, the United States and the international community have experienced multiple acts of terrorism and bioterrorism which have targeted civilians.

World War I: Germany launched a biological sabotage campaign in France, Romania, Russia, and the United States by infecting horses and mules with glanders, a virulent disease

- 1972: Two college students, Allen Schwander and Stephen Pera, were arrested for planning to poison the Chicago water supply with typhoid bacteria

- 1984: The Bhagwan Shree Rajneesh followers in Oregon attempted to affect a local election by infecting doorknobs and salad bars in restaurants with Salmonella typhimurium bacteria

- 1993: Aum Shinrikyo religious group released anthrax in Tokyo

- 1995: Bombing of the Murrah Federal Building in Oklahoma City

- 2001: Airline attack on the World Trade Center

- 2001: Anthrax-laced of infectious anthrax were delivered to news media offices and the US Congress

- 2009: Medical center attack at a Fort Hood, Texas

- 2014: Bombing of the Boston Marathon

- 2017, North Korean agents used VX, a nerve agent, to assassinate the half-brother of the North Korean leader

- Present: Multiple bombings worldwide

Radiation Exposure

Radiation exposure may involve irradiation or contamination². Contamination may be external or internal. External contamination occurs when particles are on the skin or clothing. Some of the particles can fall or be rubbed off, which results in other people and objects being contaminated. Internal contamination is having radioactive material within the body. The material may enter the body through ingestion, inhalation, or through breaks in the skin. Once in the body, radioactive material may be transported to various sites, such as bone marrow, where it continues to emit radiation until it decays or is removed.

Radiation Syndrome

Acute radiation syndrome can occur because of internal radiation contamination. Radiation syndrome includes cerebrovascular syndrome, gastrointestinal syndrome, and hematopoietic syndrome.

Irradiation is exposure to radiation but not radioactive material. In this instance, no contamination occurs. Radiation exposure can occur without one being in contact with the radiation source. When the source of the radiation is removed or turned off, exposure ends. Irradiation can involve the whole body or a small part of the body which can result in local effects. People do not become radioactive following irradiation.

Treatment of Acute Radiation Syndrome

The following provides overall treatment for acute radiation syndrome:¹²

Nuclear Weapon

A nuclear weapon is a weapon that uses nuclear fission reactions to create an explosion.¹ When a nuclearfission reaction occurs, the nucleus of a large atom is broken down into smaller ones, releasing large amounts of energy. This kind of reaction also produces neutrons, and those neutrons can cause more fission reactions. Putting enough radioactive material together creates a chain reaction, as each fission reaction causes multiple other reactions until all the material is used up.

Inside a nuclear weapon, there is a barrier between multiple small sections of nuclear material. That barrier is suddenly removed to make a single mass large enough for a chain reaction, and that single mass is exposed to a source of neutrons to start the reaction. Nuclear weapons can destroy entire cities at once and are so reviled that only two were ever used in warfare: the two bombs the USA dropped on the Japanese cities of Hiroshima and Nagasaki to end World War II.

To date, other than the dropping of nuclear bombs by the United States to end World War II, there have been no recent acts of nuclear attack or nuclear terrorism. Nuclear terrorism is an act of terrorism in which a terrorist organization detonates a nuclear device. The possibility of terrorist organizations using nuclear devices is considered plausible as terrorists could acquire a nuclear weapon. However, despite thefts of small amounts of fissile material, there is no credible evidence any terrorist group has succeeded in obtaining the necessary mass amounts of weapons-grade plutonium required to make a nuclear weapon.

Explosives

The use of explosives has been the preferred terrorist technique in recent years and is often complicated by suicide bombings. Even though the number of injuries and deaths by terrorist suicide bombings is unprecedented in recent history, suicide bombings did occur in World War II during the battle in Okinawa in 1945. In recent years, the use of explosives by terrorists has unfortunately, become a common event on an international scale, when they use explosive devices to cause injury and death within civilian populations.

Biological Weapons

In a biological warfare terror event, healthcare providers must deal with uncommon pathogens that rarely affect humans. Healthcare facilities will be inundated with victims. The arrival of one or more victims with an odd presentation may be the initial indication that an act of terrorism has occurred.

All healthcare providers should have the knowledge to identify and initiate a local response to an act of bioterrorism. The starting point is the status quo or their normal patient population. If there is a significant deviation from the norm, the provider should consider the fact that they may be on the cusp of an endemic deliberately perpetrated on society.

Providers must be aware of clinical features including:¹¹

- A cluster of persons with similar symptoms from a common geographical area

- A rapid increase in patients presenting with similar signs and symptoms

- An increase in patients who expire within 72 hours after hospitalization

- An unusual clinical presentation

- Increased dead animals

- Signs and symptoms of biologic warfare agents

- Sudden increases in calls or visits

- Sudden increases in the use of over-the-counter drug purchases

These factors reflect changes from the norm within a community. An astute healthcare provider with a sense of the community’s general normal health can make a significant difference in how soon a response to the threat begins. If the patient says that they have not had any recent foreign travel in areas of rare viruses and the suspicion is high, contacting the local health department or CDC must occur.

The Center for Disease Control has identified 30 organisms that might be weaponized by terrorists.⁹ The 30 organisms have been grouped into three categories based on ease of dissemination, morbidity and mortality, panic potential, and level of public health requirements.

Anthrax

Anthrax is a serious infectious disease caused by gram-positive, rod-shaped bacteria known as Bacillus anthracis. Although it is rare, people can get sick with anthrax if they contact infected animals or contaminated animal products. Anthrax spores are highly permeable to the porous skin. An anthrax vaccine does exist, but it is not readily available to the public and requires many injections to be effective.

The anthrax fatality rate is approximately 20% if symptoms are left untreated. If symptoms are treated, the fatality rate is drastically reduced to approximately, 1%.

Botulism

Botulism is a neurologic disorder that causes life-threatening neuro-paralysis as a result of a neurotoxin produced by Clostridium botulinum.⁷ The three main clinical presentations of botulism are as follows: Infant botulism, Foodborne botulism, and Wound botulism.

Plague: Bubonic

Bubonic plague is a highly contagious, acute, febrile illness transmitted to humans by the bite of a rat flea. Human-to-human transmission is rare. The disease is caused by a rod-shaped bacterium known as Yersinia pestis.⁴ Bubonic plague has spread worldwide, but it is more commonly reported in developing countries. Survival of the bacillus depends on the flea-rodent interaction as human infection does not contribute to the bacteria’s survival in nature.

The plague has a high fatality rate without treatment. Historically, it caused the Black Death in medieval Europe where approximately half of Europe’s population died. Due to its high death rate and potential for aerosolization, it is considered a to have a high potential for bioterrorism.

Smallpox

Smallpox is a highly contagious acute disease caused by the variola virus, an Orthopoxvirus in the Poxviridae family.¹⁴

The fatality rate of smallpox is 20% to 40%. According to the World Health Organization, smallpox was eradicated in 1980. As a weapon smallpox is particularly dangerous because it is highly contagious. Due to the infrequency with which vaccines are administered most people are unprotected in the event of an outbreak.

Tularemia or “Rabbit Fever”

Tularemia or rabbit fever is caused by Francisella tularensis which is a bacteria spread by ticks, deer flies, or contact with infected animals. It may be also be spread by breathing contaminated dust or drinking contaminated water.²

Tularemia has a low fatality rate, if treated.

Viral Hemorrhagic Fever

Viral hemorrhagic fevers are caused by a viral infection. They are caused by five families of ribonucleic acid viruses: namely Arenaviridae, Bunyaviridae, Filoviridae, Flaviviridae, and Rhabdoviridae. Fever and bleeding disorders characterize all types of viral hemorrhagic fevers and all can progress to high fever, shock, and death.³

Fatality rates of viral hemorrhagic fevers range from 25% to 90%.

Abrin Toxin

Abrin is a toxic toxalbumin that is found in the seeds of the rosary pea Abrus precatorius.⁹ Abrin is a ribosome inhibiting protein similar to the ricin, however it is more toxic than ricin.

Brucellosis

Brucellosis is a very contagious zoonosis that may be contracted by consumption of undercooked meat, unpasteurized milk, or contact with other secretions. It is also known as Mediterranean fever, Malta fever, or Undulant fever. Brucella is small gram-negative, nonmotile, non-spore-forming, rod-shaped coccobacilli bacteria. It is a facultative intracellular parasite resulting in chronic disease.

Epsilon Toxin

Epsilon toxin is produced by Clostridium perfringens types B and D and is one of the most potent poisonous substances known.⁹ Epsilon toxin binds to endothelial cells of brain capillary vessels before passing through the blood-brain barrier.

Food Bacterium

The foodborne disease usually results from food contaminated by pathogenic bacteria, viruses, parasites, or toxins such those found in poisonous mushrooms. The incubation period ranges from hours to days depending on the agent and the amount of consumption.

Glanders

Glanders is an infectious disease that usually affects donkeys, horses, and mules; however, it can also be contracted by cats, dogs, goats, and humans. It is caused by Burkholderia mallei from contaminated feed or water.⁹

Melioidosis

Melioidosis is an infection caused by gram-negative Burkholderia pseudomallei found in the soil and water. It is phylogenetically related closely to Burkholderia mallei which causes glanders.⁹

Psittacosis

Psittacosis, parrot fever, or ornithosis is caused by Chlamydia psittaci and contracted from infected parrots.⁹

Q Fever

Coxiella burnetii causes Q fever. The bacteria are found in cattle, goats, sheep, cats, and dogs. Infection occurs from inhalation from a spore-like variants and contact with feces, milk, semen, and urine of infected animals. The bacterium is an obligate intracellular parasite.⁹

Ricin

Ricin is a toxic lectin produced by the castor oil plant and found in the seeds. A dose the size of a few grains of table salt can kill a human. Injection or inhalation is more toxic than oral ingestion.

Staphylococcus Aureus

Staphylococcus aureus is a gram-positive bacterium frequently found in the flora of the nose, respiratory tract, and skin. It is a common cause of abscesses, food poisoning, respiratory infections, and sinusitis. Pathogenic strains produce virulence factors such as protein toxins and cell-surface protein that binds and inactivates antibodies. Antibiotic-resistant methicillin-resistant S. aureus (MRSA) is a worldwide problem.

Typhus

Typhus, also known as typhus fever, is caused by Rickettsia prowazekii which is spread by body lice and Orientia tsutsugamushi, chiggers, and Murine typhus, due to Rickettsia typhi spread by fleas.

Viral Encephalitis

Encephalitis is an acute inflammation of the brain caused by either a viral infection or the immune system mistakenly attacking brain tissue. Encephalitis refers to an acute, diffuse, inflammatory process. While meningitis is an infection of the meninges, a combined meningoencephalitis can occur. An infection by a virus is the most common cause of encephalitis.

Water Supply Threats

The water supply and water treatment facilities are a possible target for terrorists.

Category C agents are emerging pathogens that could be engineered for mass destruction because of their availability, ease of production and dissemination, mortality rate, and ability to cause a substantial health impact.⁹

H1N1 Influenza

Influenza A (H1N1) virus is a subtype of influenza A and a common cause of the human flu. It is an orthomyxovirus that contains haemagglutinin and neuraminidase. Haemagglutinin causes red blood cells to clump together. Neuraminidase is a glycoside hydrolase enzyme that moves the virus particles through the infected cell.

Hantavirus

Hantaviruses or orthohantaviruses are single-stranded, enveloped, negative-sense ribonucleic acid viruses within the Hantaviridae family of the order of Bunyavirales.⁹ These viruses have the potential to kill humans. Humans become infected from contact with rodent feces, saliva, or urine.

HIV/AIDS

Human immunodeficiency virus and acquired immune deficiency syndrome are conditions caused by infection with human immunodeficiency virus.

Nipah Virus

Nipah virus (NiV) infection is a zoonosis that causes severe disease in humans. The natural host of the virus is the fruit bats of the Pteropodidae family, Pteropus genus.⁹ Human-to-human transmission has also been documented. NiV infection in humans has a range of clinical presentations, from asymptomatic infection to acute respiratory syndrome and encephalitis.

Severe Acute Respiratory Syndrome

Severe acute respiratory syndrome (SARS) is a zoonotic viral respiratory disease caused by the SARS coronavirus.

When a bioterrorism attack is suspected, prehospital and hospital personal should be in communication and prepared for the anticipated surge capacity in patients requiring treatment. The inclusion of all local hospitals is essential in contingency plans as the number of severely injured patients may be overwhelming.¹¹

In considering the command structure, one must consider the inclusion of a Law Enforcement Medical Coordinator (LEMC), who is a tactical medical officer and understands both tactical and emergency medical services (EMS) issues. The LEMC would be involved in any operational input and would serve as a liaison with EMS and the fire department.

The area around the terrorist attack would have to be sectioned off into an inner danger zone, a hot zone (non-permissive zone), warm zone (semi-permissive zone), and an outer cold zone (permissive zone) where the casualty clearing station is placed. The warm or cold zones are typically where triage occurs.

Security is essential at the scene of the event. Health responders must verify with police or security services that the site is safe before they enter a scene and begin resuscitation and rescue efforts. Usually, law enforcement personnel such as SWAT paramedics will enter the inner danger zone, however if they find a victim, they should only perform basic life-saving procedures such as massive hemorrhage control, opening the airway, and rapid evacuation. They need to be mobile and therefore do not carry enough equipment for sustained care for large numbers of casualties. Any casualties should be placed in a cold zone; a location outside of the area that may be threatened by the terrorist or potential bomb. The cold zone is a safe area and includes the ability to administer resuscitation or advanced analgesia and perform other procedures. The warm zone: a semi-permissive environment, is in a spectrum between the non-permissive and permissive areas. In this area, the immediate threat is no longer active. If this is due to CBRN, then proper personal protective equipment (PPE) is required.

Protocols were created for first responders to terrorist mass casualty incidents. These include¹¹:

- 3 Echo Protocol- Enter, Evaluate, and Evacuate, which emphasizes early identification of casualties, usually by law enforcement and early treatment of life-threatening hemorrhage, and safe evacuation.

- THREAT acronym- Threat suppression, Hemorrhage control, Rapid Extrication, Assessment, and Transport.

- Emergency Medical Services (EMS) receive instruction in S-C-ABC-format, where S – safety first, C-catastrophic hemorrhage, and then the ABCs; airway, breathing, and circulation.

First Responder Practices

Triage

- Various field triage strategies exist. These include: START (Simple Triage and Rapid Treatment: the ability to obey commands, assess respiratory rate, and radial pulse or capillary refill)

- SALT (Sort, Assess, Life-Saving Interventions, Treatment, and/or Transport)

- Triage Sieve and Sort (using respiratory rate and either capillary refill or heart rate)

- Care Flight Triage (ability to obey commands, the presence of respiration, and being able to palpate a radial pulse).

Implementation of one of these protocols is essential. The most severely injured patients are usually taken to the closest level one trauma centers. However, other considerations such as the large numbers of casualties or severity of life-threatening injury may result in patient transport to the nearest medical centers for emergency treatment and stabilization. Some patients will then undergo secondary transfer to a level one trauma center.

Catastrophic Hemorrhage

Direct pressure with bandages to the injury is the initial protocol. Tourniquets should be applied to the extremities when required due to life-threatening arterial bleeding. The emergency services responder can also use hemostatic agents to areas such as the axilla and groin. Elevating and splinting of affected limbs is crucial. If the pelvis is unstable then using a sheet as a binder may be necessary.

Chemical Terrorism

The emergency responder must don appropriate protective gear when use of a chemical agent is suspected in terrorism. The personal protective equipment ranges from Level A, which consists of a chemically resistant suit and full-face self-contained breathing apparatus to Level D, which consists of overalls and no respiratory protection. It is notable that some experts advocate the decontamination of all toxicological mass casualty victims at the hospital. While in protective gear, the emergency services provider can undress the victim in the ambulance and then proper decontamination can be done at the hospital.

Biological Terrorism

Depending on the type of agent, precautions need to be taken by emergency services personnel. These range from contact and airborne precautions to the need for N95 protective respirators. The patient may have to be isolated from other patients both pre-hospital as well as in the hospital. The emergency services provider may require pre-exposure and post-exposure prophylaxis for bioterrorism agents.

Radiological and nuclear terrorism

Management of a radiological disaster must be with personal protective equipment that includes masks, eye protection, gowns, gloves, and boots. There will also be a hot zone, a warm zone (buffer zone), and cold zone. The victims should be evaluated with a Geiger counter to identify their contamination level with radioactive material. If contaminated, they should undergo decontamination. Clothes should be removed and double bagged. External decontamination should be completed by washing the face and body with soap and water. Internal decontamination may later be necessary.

Stress Response

Terrorist attacks can be as emotionally intense as any other major mass casualty event; emergency service providers frequently suffer from at least short-term post-traumatic stress. Counseling for critical incident stress is a recommended strategy. Empathetic care must begin from the time the patient arrives in the emergency department and continue throughout the process of their medical care. To prevent depression and PTSD, disaster preparedness training, critical incident stress debriefing, and shift work in prolonged responses are helpful.

Local health authorities, including emergency services, should examine their preparedness repeatedly for a potential bioterrorist attack and routinely review coordination issues with agencies that take place in response. Programs aimed to coordinate and direct emergency preparedness and responses of the emergency service personnel including anti-bioterrorism efforts should be practiced. When a public health emergency is identified, all healthcare providers must be adequately prepared to care for potential victims. This begins in the prehospital setting where decontamination and treatment is initiated and continues upon arrival to the hospital setting. The treatment regimen should coincide with the suspected weapon as evidenced by the patients’ signs and symptoms. It is important for each provider to acquire the information and skills needed to respond appropriately to a terrorist attack, and to limit to the morbidity and mortality associated with the weapon of mass destruction used.

- Aven, T., & Guikema, S. (2015). On the concept and definition of terrorism risk. Risk Analysis, 35(12), 2162-2171. https://doi.org/10.1111/risa.12518

- Barras, V., & Greub, G. (2014). History of biological warfare and bioterrorism. Clinical Microbiology and Infection, 20(6), 497-502. https://doi.org/10.1111/1469-0691.12706

- Cenciarelli, O., Gabbarini, V., Pietropaoli, S., Malizia, A., Tamburrini, A., Ludovici, G. M., Carestia, M., Di Giovanni, D., Sassolini, A., Palombi, L., Bellecci, C., & Gaudio, P. (2015). Viral bioterrorism: Learning the lesson of Ebola virus in West Africa 2013–2015. Virus Research, 210, 318-326. https://doi.org/10.1016/j.virusres.2015.09.002

- Chemical weapons: Frequently asked questions. (n.d.). Arms Control Association | The authoritative source on arms control since 1971. https://www.armscontrol.org/factsheets/Chemical-Weapons-Frequently-Asked-Questions#I

- Edwards, D. S., Barnett-Vanes, A., Narayan, N., & Patel, H. D. (2016). Prophylaxis for blood-borne diseases during the London 7/7 mass casualty terrorist bombing: A review and the role of bioethics. Journal of the Royal Army Medical Corps, 162(5), 330-334. https://doi.org/10.1136/jramc-2015-000546

- Greaves, I., & Byers, M. (2006). Respiratory protection for health care workers. Journal of the Royal Army Medical Corps, 152(4), 225-230. https://doi.org/10.1136/jramc-152-04-06

- Joseph, B., Brown, C. V., Diven, C., Bui, E., Aziz, H., & Rhee, P. (2013). Current concepts in the management of biologic and chemical warfare causalities. Journal of Trauma and Acute Care Surgery, 75(4), 582-589. https://doi.org/10.1097/ta.0b013e3182a11175

- Kotora, J. G. (2015). An assessment of chemical, biological, radiologic, nuclear, and explosive preparedness among emergency department healthcare providers in an inner city emergency department. Journal of Emergency Management, 13(5), 431. https://doi.org/10.5055/jem.2015.0253

- Moran, G. J. (2002). Threats in bioterrorism II: CDC category B and C agents. Emergency Medicine Clinics of North America, 20(2), 311-330. https://doi.org/10.1016/s0733-8627(01)00003-7

- NVHAN home. (2020, March 3). https://dpbh.nv.gov/Programs/NVHAN/NVHAN_-_Home/

- Public health emergency response Guide|Preparation & planning. (2019, March 21). Emergency Preparedness and Response | CDC. https://emergency.cdc.gov/planning/responseguide.asp

- Radiation exposure and contamination – Injuries; Poisoning – Merck manuals professional edition. (n.d.). Merck Manuals Professional Edition. https://www.merckmanuals.com/professional/injuries-poisoning/radiation-exposure-and-contamination/radiation-exposure-and-contamination

- Syndromic surveillance and bioterrorism-related epidemics. (2011, January 10). Emerging Infectious Diseases journal. https://wwwnc.cdc.gov/eid/article/9/10/03-0231_article

- Voigt, E. A., Kennedy, R. B., & Poland, G. A. (2016). Defending against smallpox: A focus on vaccines. Expert Review of Vaccines, 15(9), 1197-1211. https://doi.org/10.1080/14760584.2016.1175305

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